Ch. 13 Clinical Judgement

Question 1

A female patient who is receiving chemotherapy for breast cancer tells the nurse, “The treatment for this cancer is worse than the disease itself. I’m not going to come for my therapy anymore.” The nurse responds by using critical thinking skills to address this patient problem. Which action is the first step the nurse would take in this process?

A) The nurse judges whether the patient database is adequate to address the problem.
B) The nurse considers whether or not to suggest a counseling session for the patient.
C) The nurse reassesses the patient and decides how best to intervene in her care.
D) The nurse identifies several options for intervening in the patient’s care and critiques the merit of each option.

Answer 1

c. The first step when thinking critically about a situation is to identify the purpose or goal of your thinking. Reassessing the patient helps to discipline thinking by directing all thoughts toward the goal. Once the problem is addressed, it is important for the nurse to judge the adequacy of the knowledge, identify potential problems, use helpful resources, and critique the decision.

Question 2

The nursing process ensures that nurses are person centered rather than task centered. Rather than simply approaching a patient to take vital signs, the nurse thinks, “How is Mrs. Barclay today? Are our nursing actions helping her to achieve her goals? How can we better help her?” This demonstrates which characteristic of the nursing process?

A) Systematic
B) Interpersonal
C) Dynamic
D)Universally applicable in nursing situations

Answer 2

b. Interpersonal. All of the other options are characteristics of the nursing process, but the conversation and thinking quoted best illustrates the interpersonal dimension of the nursing process.

Question 3

An experienced nurse tells a beginning nurse not to bother studying too hard, since most clinical reasoning becomes “second nature” and “intuitive” once you start practicing. What thinking below should underlie the beginning nurse’s response?

A) Intuitive problem solving comes with years of practice and observation, and novice nurses should base their care on scientific problem solving.
B) For nursing to remain a science, nurses must continue to be vigilant about stamping out intuitive reasoning.
C) The emphasis on logical, scientific, evidence-based reasoning has held nursing back for years; it is time to champion intuitive, creative thinking!
D) It is simply a matter of preference; some nurses are logical, scientific thinkers, and some are intuitive, creative thinkers.

Answer 3

a. Beginning nurses must use nursing knowledge and scientific problem solving as the basis of care they give; intuitive problem solving comes with years of practice and observation. If the beginning nurse has an intuition about a patient, that information should be discussed with the faculty member, preceptor, or supervisor. Answer b is incorrect because there is a place for intuitive reasoning in nursing, but it will never replace logical, scientific reasoning. Critical thinking is contextual and changes depending on the circumstances, not on personal preference.

Question 4

The nurse uses blended competencies when caring for patients in a rehabilitation facility. Which examples of interventions involve cognitive skills? Select all that apply.

A) The nurse uses critical thinking skills to plan care for a patient.
B) The nurse correctly administers IV saline to a patient who is dehydrated.
C) The nurse assists a patient to fill out an informed consent form.
D) The nurse learns the correct dosages for patient pain medications.
E) The nurse comforts a mother whose baby was born with Down syndrome.
F) The nurse uses the proper procedure to catheterize a female patient.

Answer 4

a, d. Using critical thinking and learning medication dosages are cognitive competencies. Performing procedures correctly is a technical skill, helping a patient with an informed consent form is a legal/ethical issue, and comforting a patient is an interpersonal skill.

Question 5

A nurse uses critical thinking skills to focus on the care plan of an older adult who has dementia and needs placement in a long-term care facility. Which statements describe characteristics of this type of critical thinking applied to clinical reasoning? Select all that apply.

A) It functions independently of nursing standards, ethics, and state practice acts.
B) It is based on the principles of the nursing process, problem solving, and the scientific method.
C) It is driven by patient, family, and community needs as well as nurses’ needs to give competent, efficient care.
D) It is not designed to compensate for problems created by human nature, such as medication errors.
E) It is constantly re-evaluating, self-correcting, and striving for improvement.
F) It focuses on the big picture rather than identifying the key problems, issues, and risks involved with patient care.

Answer 5

b, c, e. Critical thinking applied to clinical reasoning and judgment in nursing practice is guided by standards, policies and procedures, and ethics codes. It is based on principles of nursing process, problem solving, and the scientific method. It carefully identifies the key problems, issues, and risks involved, and is driven by patient, family, and community needs, as well as nurses’ needs to give competent, efficient care. It also calls for strategies that make the most of human potential and compensate for problems created by human nature. It is constantly re-evaluating, self-correcting, and striving to improve

Question 6

A nurse is caring for a patient who has complications related to type 2 diabetes mellitus. The nurse researches new procedures to care for foot ulcers when developing a care plan for this patient. Which QSEN competency does this action represent?

A) Patient-centered care
B) Evidence-based practice
C) Quality improvement
D) Informatics

Answer 6

c. Quality improvement involves routinely updating nursing policies and procedures. Providing patient-centered care involves listening to the patient and demonstrating respect and compassion. Evidence-based practice is used when adhering to internal policies and standardized skills. The nurse is employing informatics by using information and technology to communicate, manage knowledge, and support decision making.

Question 7

A nurse is assessing a patient who is diagnosed with anorexia. Following the assessment, the nurse recommends that the patient meet with a nutritionist. This action best exemplifies the use of:

A) Clinical judgment
B) Clinical reasoning
C) Critical thinking
D) Blended competencies

Answer 7

a. Although all the options refer to the skills used by nurses in practice, the best choice is clinical judgment as it refers to the result or outcome of critical thinking or clinical reasoning—in this case, the recommendation to meet with a nutritionist. Clinical reasoning usually refers to ways of thinking about patient care issues (determining, preventing, and managing patient problems). Critical thinking is a broad term that includes reasoning both outside and inside of the clinical setting. Blended competencies are the cognitive, technical, interpersonal, and ethical and legal skills combined with the willingness to use them creatively and critically when working with patients.

Question 8

A nurse working in a long-term care facility bases patient care on five caring processes: knowing, being with, doing for, enabling, and maintaining belief. This approach to patient care best describes whose theory?

A) Travelbee’s
B) Watson’s
C) Benner’s
D) Swanson’s

Answer 8

d. Swanson (1991) identifies five caring processes and defines caring as “a nurturing way of relating to a valued other toward whom one feels a personal sense of commitment and responsibility.” Travelbee (1971), an early nurse theorist, developed the Human-to-Human Relationship Model, and defined nursing as an interpersonal process whereby the professional nurse practitioner assists an individual, family, or community to prevent or cope with the experience of illness and suffering, and if necessary to find meaning in these experiences. Benner and Wrubel (1989) wrote that caring is a basic way of being in the world, and that caring is central to human expertise, curing, and healing. Watson’s theory is based on the belief that all humans are to be valued, cared for, respected, nurtured, understood, and assisted.

Question 9

The nurse practices using critical thinking indicators (CTIs) when caring for patients in the hospital setting. The best description of CTIs is:

A) Evidence-based descriptions of behaviors that demonstrate the knowledge that promotes critical thinking in clinical practice
B) Evidence-based descriptions of behaviors that demonstrate the knowledge and skills that promote critical thinking in clinical practice
C) Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice
D) Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, standards, and skills that promote critical thinking in clinical practice

Answer 9

c. Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice.

Question 10

A nurse is caring for a client who is 24 hr postoperative following an inguinal hernia repair. The client is tolerating clear liquids well, has active bowel sounds, and is expressing a desire for “real food.” The nurse tells the client, “I will call the surgeon and ask for a change in diet.” The surgeon hears the nurse’s report and prescribes a full liquid diet. The nurse used which of the following levels of critical thinking?

A. Basic
B. Commitment
C. Complex
D. Integrity

Answer 10

A. CORRECT: At the basic level, thinking is concrete and based on a set of rules (obtaining the prescription for diet progression).

Question 11

A nurse receives a prescription for an antibiotic for a client who has cellulitis. The nurse checks the client’s medical record, discovers that the client is allergic to the antibiotic, and calls the provider to request a prescription for a different antibiotic. Which of the following critical thinking attitudes did the nurse demonstrate?

A. Fairness
B. Responsibility
C. Risk-taking
D. Creativity

Answer 11

B. CORRECT: The nurse is responsible for administering medications in a safe manner and according to standards of practice. Checking the medical record for allergies helps ensure safety

Question 12

A newly licensed nurse is considering strategies to improve critical thinking. Which of the following actions should the nurse take? (Select all that apply.)

A. Find a mentor.
B. Use a journal to write about the outcomes of clinical judgments.
C. Review articles about evidence-based practice.
D. Limit consultations with other professionals involved in a client’s care.
E. Make quick decisions when unsure about a client’s needs.

Answer 12

A. CORRECT: Learning from the experience of peers can improve critical thinking.
B. CORRECT: Journaling about decision making can assist the nurse with self reflections and improve critical thinking.
C. CORRECT: Improving knowledge by learning new information about evidence-based practice improves the nurse’s ability to think critically.

Question 13

A nurse is caring for a client who has a new prescription for antihypertensive medication. Prior to administering the medication, the nurse uses an electronic database to gather information about the medication and the effects it might have on this client. Which of the following components of critical thinking is the nurse using when he reviews the medication information?

A. Knowledge
B. Experience
C. Intuition
D. Competence

Answer 13

A. CORRECT: By using the electronic database, the nurse takes the initiative to increase their knowledge base, which is the first component of critical thinking.

Question 14

A nurse uses a head‑to‑toe approach to conduct a physical assessment of a client who will undergo surgery the following week. Which of the following critical thinking attitudes did the nurse demonstrate?

A. Confidence
B. Perseverance
C. Integrity
D. Discipline

Answer 14

A. CORRECT: By using the electronic database, the nurse takes the initiative to increase their knowledge base, which is the first component of critical thinking.

Question 15

Maslow’s Hierarchy of Needs

Answer 15

1. Physiological
2. Safety
3. Love & Belonging
4. Esteem
5. Self-actualization

Question 16

What is the safety and risk reduction priority setting framework?

Answer 16

Gives priority to the patient with the greatest safety risk, which in turn produces a risk reduction

Question 17

A nurse is collecting data on four clients. Which of the following is the highest priority finding by the nurse?

A) Malaise
B) Anorexia
C) Headache
D) Diarrhea

Answer 17

D) Diarrhea

ABC
Diarrhea can deplete the body of fluids and cause a decrease in the circulating blood volume.

Question 18

A nurse in a rehabilitation facility has received report on four clients. Which of the following should the nurse evaluate first?

A) A client who has peripheral vascular disease and reports numbness in the toes
B) client who has depression & is easily distracted
C) A client who has Alzheimer’s disease and is unable to complete ADLS
D) A client who had abdominal surgery 10 days ago and reports feeling his incision pop

Answer 18

D) A client who had abdominal surgery 10 days ago and reports feeling his incision pop

acute vs. chronic
Clients often report feeling the incision pop, indicating either dehiscence or evisceration has occurred.

Question 19

A nurses caring for an older adult client who recently experienced the death of her partner. Which of the following is the priority need of the client?

A) establishing a sense of achievement
B) contributing to society
C) creating meaningful social relationships
D) enhancing self- confidence

Answer 19

Creating meaningful social relationships

Maslows Hierarchy of needs
Social relationships are a component of friendship, which would be included in the 3rd level.

Question 20

A nurse is preparing to administer oral medication to a client who has unilateral weakness following a cerebrovascular accident (CVA). Which of the following should be the priority action of the nurse?

A) Administer medications w/ meals when possible
B) Ensure client understanding of medication’s effects
C) Determine the client’s ability to self-administer meds
D) have the client position the head w/ chin down while swallowing

Answer 20

Have the client position the head with the chin down while swallowing

safety and risk reduction
Clients are at risk for aspiration following a CVA, and having the client position the head with the chin down while swallowing reduces this risk.

Question 21

A nurse is conducting therapeutic medication monitoring on four clients. Which of the findings should be immediately reported to the provider?

A) Lithium carbonate 0.8
B) Digoxin 3.0
C) Peak serum gentamicin 6 mcg/mL
D) Mag. Sulfate 4

Answer 21

Digoxin 3.0ng/mL

unstable vs. stable
This digoxin level is above the expected reference range and indicates digoxin toxicity.

Question 22

A nurses caring for a client who has a urinary track infection. The client is disoriented and found wandering on another unit. Which of the following actions should the nurse take first?

A) Ensure all 4 side rails are up.
B) Administer a prescribed sedative.
C) Place the client in soft wrist restraints
D) Move the client to a room near the nurses’ station

Answer 22

Move the client to room near the nurses station

least restrictive, least invasive
Moving the client to a room near the nurses station allows for more frequent observation and promotes client safety.

Question 23

A nurse is reinforcing discharge teaching to a new mother regarding sudden infant death syndrome (SIDS). Which of the following is the highest priority to include in the instructions?

A) Place the infant in a supine position when sleeping
B) place the infant on a firm mattress when sleeping
C) avoid covering the infant with loose bedding while sleeping
D) avoid leaving stuffed animals in the crib with the sleeping infant

Answer 23

Place the infant in a supine position when sleeping

safety and risk reduction
This intervention has had the greatest impact on reducing the occurrence of SIDS.

Question 24

A nurse is caring for a client who has a serum potassium level of 3.1 mEq/L. Which of the following actions should the nurse take first?

A) obtain an ECG.
B) Administer oral potassium
C) Encourage potassium-rich foods
D) Monitor I & O

Answer 24

A) Obtain an ECG

Maslows Hierarchy of needs
Obtaining an eCG will assist in determining the presence of dysrhythmias related to a serum potassium level below the expected reference range.

Question 25

A nurse is caring for a client who is having difficulty breathing. Which of the following actions should the nurse take first?

A) Place O2 at 2 L per nasal canula on the client
B) Place the client in the orthopneic position
C) Perform chest percussion
D) perform nasotracheal suction

Answer 25

B) Place the client in the orthopneic position

least restrictive, least invasive
Placing the client in the orthopneic position allows for maximum chest expansion, which improves respiratory effort.

Question 26

A nurse is collecting data on four clients. Which of the following findings is the most urgent?

A) bladder distension and urgency
B) pedal edema
C) warmth and pain in the calf
D) hypoactive bowel sounds

Answer 26

Warmth and pain in the calf

urgent vs. non-urgent
Warmth and pain in the calf is indicative of deep-vein thrombosis, which places the client at risk for pulmonary embolism.

Question 27

A nurse in an urgent care clinic is caring for a client who has bronchitis with thick pulmonary secretions. The client’s oxygen saturation level is 90% on room air. Which of the following actions should the nurse take first?

A) Initiate oxygen therapy
B) encourage an increase in oral fluids
C) provide room humidification
D) Assist client to cough effectively

Answer 27

D) Assist client to cough effectively

ABC
Assisting the client to cough effectively opens the airway by removing secretions.

Question 28

A nurse in a long-term care facility is assisting with the admission of several clients. To prevent falls in hospitalized clients, which of the following actions should the nurse take first?

A) Provide assistance w/ ambulation when indicated
B) Determine the mobility status of each patient
C) Maintain the side rails of each be in the raised position
D) Plan a fall prevention program for clients at risk

Answer 28

B) Determine the mobility status of each patient

nursing process/data collection
Determining the mobility status of each client will help to identify those patients who are at risk for falls.

Question 29

A nurse is reviewing the lab results for four clients. The client with which of the following values requires immediate intervention?

A) Cholesterol 220 mg/dL
B) Platelets 95,000 mm^3
C) BUN 20 mg/dL
D) Potassium 3.5 mEq/L

Answer 29

B) Platelets 95,000 mm3

unstable vs. stable
This platelet level is below the expected reference range and indicates the client is at risk for bleeding.

Question 30

A nurse working on the cardiac unit hears an alarm and finds one of the heart monitor screens at the nurse’s station is displaying a straight line, indicating a client is in cardiac arrest. Which of the following actions should the nurse take first?

A) Check on the client
B) unlock the crash cart
C) begin cardiopulmonary resuscitation
D) announce a code

Answer 30

A) Check on the client

nursing process/data collection
If the client is able to be aroused or a pulse is palpated, then the client is not in cardiac arrest, and there is a problem with the monitoring equipment. Leads also could fall off.

Question 31

A nurses caring for a client who is in the immediate post operative period following a tracheotomy. Which of the following is the nurses priority action?

A) providing pain control
B) preventing hemorrhage
C) maintaining a patent airway
D) ensuring adequate fluid intake

Answer 31

Maintaining a patent airway

ABC
An airway obstruction is a potential complication for clients following head and neck surgery secondary to production of mucus and needs for suctioning.

Question 32

A newly hired nurse is reviewing the facilities emergency preparedness plan. Based on a review of the four triage categories, the nurse should provide power you care to clients who are in which of the following categories during a disaster?

A) immediate
B) delayed
C) minimal
D) expectant

Answer 32

Immediate

survival potential priority
Clients assigned to the immediate triage category in a mass casualty event have life-threatening, but survivable injuries if immediate care is received.

Question 33

A nurse in a provider’s office has collected data on four clients. Which of the following clients should be the nurse’s priority concern?

A) a client who is has a history of HF
B) a client who has type 1 DM
C) a client who is reporting pain associated w/ osteoarthritis of the knees
D) a client who is having a nosebleed associated w/ hypertension

Answer 33

A client who is having a nosebleed associated with hypertension

acute vs. chronic
A nose bleed, or epistaxis, is an acute condition requiring immediate intervention to prevent further blood loss.

Question 34

A nurse is caring for a client who is diagnosed with gastroenteritis. Which of the following actions should the nurse take first when evaluating for fluid volume deficit?

A) obtain an arterial pH level
B) check the HR and BP
C) insert an indwelling cath
D) collect a serum BUN and creatinine

Answer 34

Check the heart rate and blood pressure

least restrictive, least invasive
An increase in heart rate and decrease in blood pressure are consistent with a fluid volume deficit.

Question 35

A nurse is assisting with the admission of a client who has decreased circulation in the left leg. Which of the following is the first action the nurse should take?

A) Administer an anticoagulant
B) Check the leg for warmth and Edema
C) Apply elastic stockings
D) Promote bed rest & extremity elevation

Answer 35

B) Check the leg for warmth and edema

Nursing process/data collection
If warmth and edema is found in the leg, this indicates that the decreased circulation could be due to a deep-vein thrombosis.

Question 36

A nurse is caring for a newly admitted client. Which of the following client needs should the nurse address first?

A) homelessness
B) lack of family support
C) Hypoxic
D) under nourished

Answer 36

C) Hypoxic

Maslows Hierarchy of needs
Hypoxemia indicates reduced blood oxygen levels, which involves the physiological needs of the client and is the first level.

Question 37

What are 3 common skills that can be delegated?

Answer 37

V/S, ADL’s, height & weight measurement